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This isn’t exactly breaking news — that happened in the craziness of HIMSS17 a couple of weeks ago — but I am now a member of The Walking Gallery of Healthcare. The Walking Gallery is a series of paintings on jackets, mostly, but not completely, created by artist/patient advocate Regina Holliday, meant to spark conversations about healthcare.

Each painting depicts a difficult healthcare situation that the wearer or a loved one of the wearer experienced. In my case, it is the story of my late father’s terrible experience in a poorly run community hospital as he was dying of a rare disease called multiple system atrophy, and my own advocacy as a result of his ordeal.

Holliday calls this one, “Miles to Go Before I Sleep,” likely because I undertook a bike tour from Chicago to Washington, D.C., in 2014 in my dad’s memory, and, likely, because I am a notorious night owl/occasional insomnia sufferer. I think there’s also some meaning in the fact that I have been a restless advocate, via my writing, for better care since I had to witness his suffering nearly five years ago. (I didn’t get to see a draft of the painting until I received my jacket, which is only fair, since as a rule, I don’t let story subjects see copies of my work prior to publication.)

The painting of me as a child is based on this photo of me as a baby. My dad didn’t have a mustache for long, but he did when I was a toddler.

To this day, my mother will tell you I was the most beautiful baby she ever saw. That’s a completely objective statement because she has no inherent bias at all.

I didn’t know what to expect, but I absolutely love the final result of the painting, which includes purple, the color of MSA awareness, at least in North America. The jacket itself cost a whopping $50 at Marshall’s because I wasn’t sure if people sent expensive or cheap sportcoats to be painted.

As you know, I’ve become rather obsessed with patient safety ever since I watched bad things happen to my dying father nearly three years ago, so I wanted to pass along a petition and gauge people’s opinions. Should cameras be mandatory in operating rooms? Some people think so. There’s obviously a growing movement in the U.S. to equip police officers with body cameras, in the name of protecting police and the public alike. There just might be a parallel for surgery teams and patients.

A petition went online late last month as Causes.com, calling on legislators to require OR cameras “to reduce harm, and learn from errors.” I learned about it from John James, founder of Patient Safety America. In an e-mail, James explained, “There are many reasons to do this: educational tool, improve performance of surgeons, document skills, have an unbiased record if an adverse occurs, and reduce misstatements in medical records.”
What do you think? Vote here, and if you are so inclined, leave a comment below.Should cameras be mandatory in U.S. operating rooms?

In a sidebar to the September cover story I did for Healthcare IT News, I reviewed some of the work of Scot Silverstein, M.D., who has long been chronicling problems with EHRs and other health IT systems. Unfortunately, he wasn’t available for an interview in time for that report, but he was last week, so I got him for a new podcast.

Silverstein, a professor of health informatics at Drexel University in Philadelphia, considers EHRs to be experimental and, sometimes, less safe than paper records and would like to see health IT subjected to the same kind of quality controls as aerospace software or medical devices. “Suboptimal system design could lead even careful users to make mistakes,” Silverstein said in this interview.

Judy Murphy, R.N., Director of the Office of Clinical Quality and Safety in the Office of the National Coordinator for Health Information Technology, and the ONC’s chief nursing officer, is stepping down Oct. 17 to become CNO of IBM Healthcare Global Business Services.

Murphy has been with the ONC since December 2011 after 25 years as a nursing and informatics expert at Aurora Health Care in Wisconsin; she had led Aurora’s EHR program since 1995. Most importantly to those of us in the media, she has never been afraid to speak her mind and provide good quotes. Now that she’s moving back to the private sector, she won’t be hamstrung by political and considerations when she gives public presentations.

According to National Coordinator Karen DeSalvo, M.D., health IT specialist Jon White, M.D., will be on part-time detail from the Agency for Healthcare Research and Quality to serve as interim head of the Office of Clinical Quality and Safety and acting ONC chief medical officer until those positions get permanent replacements. (Former ONC CMO Jacob Reider, MD, is now deputy national coordinator.) Andy Gettinger, M.D., of Dartmouth Hitchcock Medical Center, will head up patient safety efforts at the ONC on an interim basis.

“Judy’s CNO responsibilities will be entrusted to the other nurses at ONC until a replacement CNO can be named,” DeSalvo said in a memo to ONC staff.

If you wonder where I’ve been, I’ve, for one thing, been blogging a bit for (very little) pay over at Forbes.com and writing a lengthy cover story for the September issue of Healthcare IT News.

The Healthcare IT News piece actually breaks down into a fairly short lead story and several sidebars, which aren’t all that evident from the traditional Web version. (The digital edition has everything.) For the sake of convenience, here are links to all elements of the cover package:

I’m back from an extended break, though hardly a vacation. I spent 11 days this month cycling from Chicago to Washington to raise awareness of multiple system atrophy, the rare neurodegenerative disease that killed my father in 2012. For my first post in more than two weeks, I’ll keep it simple but important, namely with an update on Health eVillages, the program I sit on the advisory board of, as well as some vaguely related news from Qualcomm.

HealtheVillages provides iPod®, iPad® and other handheld devices equipped with specialized reference and clinical decision support tools to improve primary and preventive healthcare in underserved areas around the world.

“We are proud to announce the addition of these five fantastic non-profit and corporate executives to our Advisory Board,” said Donato Tramuto, the Founder of HealtheVillages. “As HealtheVillages continues to grow its presence across the globe, we are excited to be able to mine the breadth and depth of experience that Brad Fluegel, Spencer Warden, Mike Hamilton, Lorri L. Jean and Ulya Khan bring to the table. We look forward to using their guidance to help shape innovative, strategic approaches to bringing quality healthcare to people in some of the most underserved areas around the world.”

Since its inception in 2011, HealtheVillages has made a significant impact in improving access to critical, live-saving medical information worldwide, launching programs in Africa, Central America, Pacific nations, the Caribbean and areas of Louisiana affected by the Gulf oil spill.

The most recent additions to the HealtheVillages Advisory Board include:

Brad Fluegel is the Senior Vice President and Chief Strategy Officer at Walgreens Co. Prior to coming to Walgreens in 2012, Fluegel was an executive at several prominent healthcare companies, including Wellpoint, Aetna, Inc., United Health Group and Tillinghast-Towers Perrin. He also serves on the Board of Directors of Metropolitan Jewish Health System in New York City,Health Integrated, Inc., and Performant Financial Corp.

Spencer Warden is the Provider Engagement Lead at Dabo Health Inc., which provides a community healthcare platform to view and track improvement in key performance metrics and allows for collaboration across hospitals and healthcare systems. Spencer’s responsibilities at Dabo Health include business development, corporate strategy, and strategic partnerships in the Hospital and Payer marketplace. He previously worked for Eli Lilly as a Sales Representative in San Francisco’s Neuroscience sleeve.

Mike Hamilton , President of Engagement at Blood: Water Mission, has received numerous honors for his work with youth and children, especially for orphan crisis issues and healthcare needs in Africa. Hamilton came to Blood: Water after 26 years in intercollegiate athletics at Clemson University, Wake Forest University, and the University of Tennessee. He also served on the board for Show Hope and chaired the Knoxville Chamber Partnership and the local United Way Chapter in Knoxville.

Lorri L. Jean is a nationally recognized leader in the lesbian, gay, bisexual and transgender (“LGBT”) civil rights movement. She serves as CEO of the L.A. Gay & Lesbian Center, the world’s largest LGBT organization. Previously, Jean served as the Executive Director of the National Gay and Lesbian Task Force. Jean was the first openly gay or lesbian person to receive a top secret security clearance from the Central Intelligence Agency, and with her appointment in 1989 as Deputy Regional Director of the Federal Emergency Management Agency (“FEMA”), she became the highest-ranking openly gay or lesbian person in the Federal government. OUT Magazine has twice named her one of the 50 most powerful gay people in the nation and Los Angeles Magazine named her one of the 100 most influential people in Los Angeles.

Ulya Khan, the Chief Operating Officer at Physicians Interactive, has more than 20 years of experience in technology, data and operations. Prior to joining Physicians Interactive, Khan held several leadership positions including Chief Operating Officer and Chief Of Staff at Thomson Reuters in London and New York City, where she was instrumental in building and exponentially growing several businesses and managing global teams across Asia, Europe and the Americas.

About HealtheVillagesHealtheVillages, a program of the not-for-profit Robert F. Kennedy Center for Justice & Human Rights and Physicians Interactive, provides state-of-the-art mobile health technology including medical reference and clinical decision support resources to medical professionals in the most challenging clinical environments around the world. For more information about HealtheVillages, please visit http://www.healthevillages.org/.

About Physicians Interactive
Headquartered in Reading, MA, PI aspires to use the power of worldwide networks of healthcare professionals and life sciences companies together in ways that will change the practice and business of medicine for the better. PI’s value proposition is to offer the life science industry a low-cost, virtual, multi-channel marketing approach that can be used to supplement currently promoted products, as well as non-promoted and orphaned products, that deliver benefits to physicians and patients. A key focus is providing services that fit into physicians’ and healthcare professionals’ daily workflow at the point-of-care when they make diagnosis, treatment and prescribing decisions. More information can be found at www.PhysiciansInteractive.com.

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Interested in seeing the kind of difference Health eVillages is making in remote parts of the world? Check out this short video about “moving the needle on global health.”

A couple weeks ago, I had a story in Healthcare IT News about the growing use of the “APSO” notes for documenting patient encounters. APSO flips around the traditional SOAP format (subjective, objective, assessment, plan), ostensibly making it easier to view progress notes in electronic health records.

As I reported, APSO is in wide use at University of Colorado Health and at Lucile Packard Children’s Hospital in Palo Alto, Calif. Baystate Health in Springfield, Mass., found that hospitalists focused most of their attention on the “impression and plan” sections of patient records, essentially the AP part of APSO/SOAP. Physicians at Epic Systems, according to University of Colorado’s Dr. C.T. Lin, are recommending APSO as a best practice.

Yet, the inventor of the SOAP note, Dr. Larry Weed, still believes his format is superior. You saw his comments in the Healthcare IT News story. But every time I have the privilege of speaking to the nonogenarian Renaissance man, he always has more to say than I can fit into the average article. I often can’t keep up in my note taking, but, fortunately, in this case, Weed and his son/occasional co-author Lincoln, took the time to put their thoughts in writing for me.

I left most of their comments out of the story due to space limitations. I don’t have that problem here, so I present their entire statement to me:

The following represents our collective thoughts, including references to relevant portions of Medicine in Denial [their 2011 book].

The supposed advantage of the APSO alternative — that it begins with the physician’s assessment rather than data — is actually a failing. This sequence tends to make the note provider-centered rather than patient-centered, and judgment-based rather than evidence-based. In contrast, beginning the progress note with data disciplines the provider’s assessment. The provider must think in terms of specific data, specific problems on the problem list to which the data relate, and the interrelationship of each problem to the other problems on the list. Moreover, it’s important to begin the progress note with subjective (symptomatic) data from the patient rather than so-called “objective” data, As Medicine in Denial states (p. 168):

“… progress notes should begin with subjective data, because progress should be assessed from the patient’s point of view. Practitioners should be alert to discrepancies between subjective and objective data (for example, where the patient does not feel better when lab results show improvement). These discrepancies may signal an error in data or misstatement of the patient’s problem.”

In short, provider thinking can be disciplined with problem-oriented SOAP notes as a standard of care. Yet, regulators and academics who are in a position to act on this issue have shied away from the whole notion of standards of care for organizing data in medical records. See our comments on ONC’s Stage 2 regs and our comments on the PCAST Report.

The need for standards of care in medical records goes far beyond the SOAP vs. APSO issue in progress notes. In fact, that issue is secondary. Two more fundamental issues for medical records are the following:

1. Determining initial inputs to the record. Initial inputs are determined by selection of data needed for the patient’s problem situation, and once the data are collected, analysis of the results. Both selection and analysis are fatally compromised when determined by the physician’s clinical judgment. External standards and tools, based on a combinatorial standard of care, must govern the selection and analysis. Once that happens, then judgments of patient and practitioners (not just physicians) may supplement the combinatorial minimum standard. See Medicine in Denial, pp. 53-61, 69-79, 136-37, 145-52.

2. Organizing the medical record around the problem list. Once initial data are collected and a complete problem list is defined, then care plans, orders, and progress notes should be problem-oriented, that is, labeled by the problem(s) to which they relate on the problem list. This disciplined practice is essential to justifying provider actions in terms of defined patient needs. Yet this practice is not followed or enforced with consistency. Indeed, some EHR systems do not even enable electronic links between the problem list and care plans, orders and progress notes. See Medicine in Denial, pp. 134-35, 144, 159-60, 166-67.

Like so much else in medicine, medical record practices are a Tower of Babel. Medicine need standards of care for managing clinical information (knowledge and data) no less than the domain of commerce needs accounting standards for managing financial information. This failing is a primary root cause of the health care system’s failures of quality and economy.

For that matter, Lin had more to say than what you saw in the story. He discussed the supposed importance of the subjective and objective elements. “That’s true in cases where there is diagnostic uncertainty,” Lin said. But he added that those components are still there for reference, jut not up front.

Lin called SOAP “a phenomenal innovation,” but suggested that EHR complexity sometimes makes it difficult to find the assessment and plan. For example, he said that a non-Epic EHR in the emergency department at UC Health has as many as 17 different screens for progress notes. “At least with APSO, you would collect the assessment or plan in the first half,” Lin said.

Because SOAP is so entrenched, Lin ran into much resistance when he proposed switching to APSO at 40 affiliated practices. He, of course, heard the tired, “But we’ve always done it this way” defense.

“I learned myself about culture change very acutely,” Lin said. “I was literally shouted out of the room by our physician leadership.” He had neglected to prepare the heads of various departments and clinics for the change in advance of the meeting where he announced the plan.

He subsequently had to have individual conversations with all 40 practice directors. And then Lin dropped a great quote from none other than Niccolo Machiavelli (speaking of Renaissance men): “Those who benefited from the old order will resist change very fiercely.”

Yes, that’s absolutely perfect for an industry as resistant to change as healthcare. But is APSO superior to SOAP? I’d love to hear your thoughts.

That reminded me of an e-mail I received a couple weeks ago, suggesting that someone should start a blog called, “What’s Eric Saying?” As this correspondent explained it, all you need to do is read Topol’s Twitter stream to know where health IT and the practice of medicine are headed. I checked it out. It’s true.

Meanwhile, Mostashari added some truisms himself this morning. “Med speed is slow. Tech speed is fast,” he said, apparently paraphrasing current TEDMED owner Jay Walker. Then, speaking as a physician, Mostashari said, “Most of what determines our outcomes isn’t what happens in our office.” Which is kind of what Topol has been trying to get across for several years.

If only the financial incentives would encourage care outside the office, we might be getting somewhere. It’s starting to happen, but, as it says above, med speed is slow.

Per Surescripts, in 2012, the latest year for which statistics are available, about 69 percent of physicians nationwide used e-prescribing technology in one way or another, and 44 percent of all prescriptions written nationwide were routed electronically. (That report came out in early May 2013, so expect some new numbers soon.) Both are up substantially from the previous year, probably due in no small part to the Meaningful Use EHR incentive program, which does require a minimal level of e-prescribing.

But what about the holdouts? A recent article in the journal Perspectives in Health Information Management found that cost remains the No. 1 reason why physicians still haven’t ditched the paper prescription pad in favor of electronic prescribing.

“While e-prescribing offers many benefits, not all providers have been excited about implementing e-prescribing systems. A major barrier, reported by more than 80 percent of primary care physicians, has been lack of financial support. New technology requires training and information technology support for installation and upkeep. A practice must take these costs into account when deciding whether to implement an e-prescribing system and also when choosing a stand-alone system or one that is integrated into an EHR system. According to the Health Resources and Services Administration, in a 2007 study the total cost of implementing an e-prescribing system was found to be $42,332, with annual costs after implementation of about $14,725 per year, for a practice of 10 full-time equivalent psychiatrists,” the authors reported.

Yes, but the paper also says this: “E-prescribing improves the efficiency of the prescribing process. Though the actual entering of a new prescription takes about 20 seconds longer per patient than writing a prescription, this time is offset by the time saved because of the fact that less clarification is needed for electronic prescriptions. Prescribers spent more time on the computer, on average an extra 6 minutes per prescriber per day or an increase of 20 seconds per patient when seeing 20 patients per day. If implemented correctly, e-prescribing should cause little disruption in the workflow of ambulatory care settings.”

In other words, those resisting the switch are being penny-wise and pound-foolish.

Besides, e-prescribing systems don’t have to cost that much. In fact, they don’t have to cost anything. Allscripts offers a free, standalone e-prescribing system online, while PracticeFusion, DrChrono and Kareo have e-prescribing modules in their free EHRs. A startup named ScriptPad has an e-prescribing app for Apple iOS that’s free to prescribers; transaction fees get billed to pharmacies. I can’t vouch for the efficacy of any of this software, but cost doesn’t have to be an issue.

I think the real problem here is intransigence. Some doctors simply don’t want to get with the times, and the only losers are patients.

You’ve no doubt hear about the kickback scandal involving CareFusion and Charles R. Denham, MD, founder of the Texas Medical Institute of Technology (TMIT). I wrote a piece about it in the context of Meaningful Use for Healthcare IT News this month, since Denham co-chaired the steering committee of the National Quality Forum’s Safe Practices for Better Healthcare program during the time CareFusion allegedly paid Denham $11.6 million to promote its products.

CMS, of course, has, to date, based Meaningful Use quality measures on NQF recommendations.

Denham has become a pariah of sorts in patient-safety circles since the U.S. Department of Justice announced a $40.1 million settlement with CareFusion in January. Yet, believe it or not, TMIT is still in business. The organization’s Web site is functional; in fact, the “about” page prominently features a video with Denham. And the TMIT Twitter account is activem, promoting a webinar as recently as yesterday.

Perry Bechtle, D.O., is a neuroanesthesiologist at Mayo Clinic in Jacksonville, Fla., and a former U.S. Navy flight surgeon. I want to believe that his credentials are impeccable, but it’s hard to take TMIT seriously these days in the absence of a major house-cleaning. Interestingly, the last academic article Denham wrote before the scandal broke was in the December 2013 issue of the Journal of Patient Safety. It’s entitled, “Safe Use of Electronic Health Records and Health Information Technology Systems: Trust But Verify,” and co-authors include heavyweights such as David Classen, M.D., and David Bates, M.D.

How are we supposed to trust an organization that itself was wrapped up in such a serious breach of trust?

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